Healthcare Provider Details

I. General information

NPI: 1063504058
Provider Name (Legal Business Name): MARTIN A. O'TOOLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 12/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

542 S FAIR OAKS AVE
PASADENA CA
91105-2606
US

IV. Provider business mailing address

PO BOX 158
LA CANADA CA
91012-0158
US

V. Phone/Fax

Practice location:
  • Phone: 626-449-8910
  • Fax:
Mailing address:
  • Phone: 626-449-8910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberG67312
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: